FARES method to reduce acute anterior shoulder dislocation: a case series and an efficacy analysis

Hong Kong Journal of Emergency Medicine FARES method to reduce acute anterior shoulder dislocation: a case series and an efficacy analysis FARES LCH Tsoi and MCK Wong Objective: Anterior shoulder dislocation is a common large joint dislocation. There is no standard method for reduction. A new technique (FARES method) was introduced by a Greek group in late 2009. Design: Case series analysis. Setting: An emergency department. Methods: A survey was conducted from April to June 2010 in the emergency department primarily to collect data on the methods of reduction of anterior shoulder dislocation and their efficacies. Results: Nine cases of anterior shoulder dislocation were documented. All 9 cases were reduced successfully regardless of the reduction methods used. FARES method was found to be popular in the studying emergency department. Six out of the 9 cases were using the FARES method at their first attempt (the rest two case using Spaso; one using traction-counter traction). No pre-medication was needed in all FARES' cases. In all 6 cases using the FARES method, the shoulder could be reduced within 2 minutes. Conclusions: Our experience concords with overseas' in which the FARES method is efficacious and fast. (Hong Kong j.emerg.med. 2012;19:65-69) 2009 FARES 2010 4 6 9 9 FARES 9 6 FARES Spaso FARES 6 FARES 2 FARES Keywords: Adult, analgesics, manipulation, orthopaedics Introduction The shoulder is implicated in the majority of acute large joint dislocations (up to 60%), 1 and amongst them 96% are anterior shoulder dislocations. Despite its common occurrence, there is no standard method Correspondence to: Tsoi Chun Hing, Ludwig, MPH, MRCP, FRCSEd North District Hospital, Accident and Emergency Department, Sheung Shui, N.T., Hong Kong Email: tch654@gmail.com Wong Chi Keung, Michael, MBBS, MRCSEd whereby one can manage this condition as a gold standard. A review article published in 2004 summarised all commonly used techniques prior to that time. 1 Most of the papers reviewed were uncontrolled case series or reviews with few studies comparing the efficacy of different techniques. There was only one randomised controlled trial (RCT) in 1986 by Beattie et al comparing Milch and Kocher techniques. 2 In 2009, Fares et al from Greece published a prospective RCT comparing a new reduction technique of anterior shoulder dislocation with Hippocratic and Kocher's methods. 3 The result was encouraging: the

66 Hong Kong j. emerg. med. Vol. 19(1) Jan 2012 FARES method was superior in terms of success rate (88.7% vs. 72.5% and 68%; p=0.033), time of reduction (2.36 minutes vs. 5.55 minutes and 4.32 minutes; p<0.001) and visual analogue scale (VAS) (1.57 vs. 4.88 and 5.44; p<0.001). One of the merits advocated by the author is that the procedure can be performed without any premedication and analgesics. The FARES reduction method for anterior shoulder dislocation rapidly gained ground in our emergency department. The present article is a case series showing how the new technique affected our management in the shoulder dislocation. Description of the FARES method The FARES method, FARES standing for "FAst, REliable and Safe (sic)", is a one-operator technique to reduce anterior shoulder dislocation. This technique utilises a new combination of mechanisms - traction, oscillation, and leverage to reduce the humeral head back to the glenoid. With the patient lying supine, the operator holds the patient's hand on the affected side while the arm is at the side, allowing elbow fully extended and the forearm in neutral position. In the original paper, no sedation or analgesic was required because comparing the pain scores of the different methods was one of the objectives in their study. Next, the operator gently applies longitudinal traction and slowly the arm is abducted. At the same time, continuous vertical oscillating movement at a rate of 2-3 "cycles" per second (Figure 1) is applied throughout the whole reduction process. The vertical movement should be short-ranged at about 5 cm above and below the horizontal plane. Since passing the 90 abduction, the arm is gently externally rotated with the palm now facing upward while keeping the vertical oscillation and traction. Reduction usually occurs at 120 abduction (Figure 2). If reduction does not occur immediately, continue the oscillatory movement while slightly increase the traction force until reduction occurs. After successful reduction, the arm is internally rotated and adducted across the chest to bring the forearm to rest in front of the patient. A more detail description with captioned photos can be found in the original Fares' article. 3 Methods A senior staff introduced the FARES method to the doctors in the emergency department. Data in the period from 1st April 2010 to 30th June 2010 were collected for cases of anterior shoulder dislocation regarding sex, age, mechanism of injury, associated fractures, time from injury to reduction, sedation or premedication used, reduction method utilised, time used for reduction, success and complications of reduction, VAS for pain and whether the current dislocation being the first episode. Figure 1. While maintaining traction (the light arrow), apply vertical oscillation at a rate of 2-3 hertz with a distance of 5 cm above and below the horizontal plane (the black arrows). Figure 2. Reduction typically occurs at 120 abduction. Maintain the traction and oscillation if reduction does not occur immediately.

Tsoi et al./fares method for anterior shoulder dislocation 67 Results The result of this series is tabulated in Table 1. In summary, there were 4 men and 5 women in our case series. The age of our group ranged from 18 to 84 years. Our mean age 50.6 (s.d. 21.0) is not statistically different from the original study's 41.2 (s.d. 17.8) (independent sample t-test, p=0.236). The main mechanism of injury was fall, 66.7% (statistically not different from the original study's 58.5%, Fisher exact test p=0.728). This is especially true for our female patients. The new method was popular (6 out of 9 counts) amongst our staff. All 9 cases were successfully reduced irrespective of the method used for reduction and all were successful in the first attempt. Our experience concords with the high success rate of Fares' original paper. The time interval between injury and reduction ranged from 1 to 6 hours, in keeping with the primary intention of this treatment for acute anterior shoulder dislocation. Sedation or premedication was only used in one case, for which the Spaso technique was used. There were 2 cases of minor fracture-dislocation involving the greater tuberosity, for which no surgical intervention was required. These two did not require analgesic before the procedure. The time needed for the reduction was quick in our series. For FARES, the range was from 10 seconds to 2 minutes (with a median/mode 20 seconds). Spaso technique was also quick, in the 2 cases we had, the time needed was 20 seconds. We asked our patients to mark on a 10-cm VAS to evaluate the pain they experienced during the reduction. This was done in line with the original paper. For the FARES group, the pain score varies from 0.4 to 9.9. When we consider all 9 cases together, it seems that sex and age do play a role in the pain perception of the reduction procedure. If we define "young male" as those "male patients 40 years old or below" and the rest as "others", and then compare the 2 groups' pain score. We found a relatively lower pain score in the "young male" group (mean 1.27 vs. "others" group 7.68) irrespective of the technique used. Our case series is too small to generate anything conclusive, but this may be a good starting point for future studies. Discussion Our case series is only a small series with a few cases trying out the new method of reduction. No solid conclusive verdict can be drawn. Yet there are several interesting points that are noteworthy. As the Greek group suggested, this new method could be mastered relatively easily. Before the commencement of the audit period, one senior staff presented the technique using the original paper's step-by-step Table 1. The results of the case series Patient Sex Age Mechanism Fracture- Time Sedation Method Time of Successful Pain Complication First no. (year) of injury dislocation interval or reduction VAS dislocation (hour) premedication (second) 1 M 18 Accident No 3 No FARES 20 Yes 0.4 No No 2 M 46 Fall No 2 No FARES 20 Yes NA No Yes 3 F 52 Fall No 2 No FARES 20 Yes NA No Yes 4 F 76 Fall No 1 No FARES 10 Yes 9.9 No Yes 5 F 48 Fall No 3 No FARES 120 Yes 7 No NA 6 F 84 Fall Yes 6 No FARES 15 Yes 6 No Yes 7 F 62 Fall No 1.25 No Spaso 10 Yes 7.8 No Yes 8 M 30 Fight No 1 Yes Spaso 10 Yes 0.9 No No 9 M 39 Car Yes 1.5 No Traction- 120 Yes 2.5 No No accident counter-traction NA= not available, VAS=visual analogue scale

68 Hong Kong j. emerg. med. Vol. 19(1) Jan 2012 approach to the other staff in a monthly meeting of the department. No workshop or hands-on were arranged. The survey was meant to collect baseline data what our practice was like at that time (early 2010). It turned out that the FARES method gained momentum rapidly and was very popular. One of the attractive features of this method is the level of evidence it carries. In the review article published in 2004, 1 Chung pointed out in this area of clinical practice, the quality of medical literature is relatively low - most of the papers were uncontrolled case reports and reviews. The only RCT was Beattie's paper in 1986. The Fares' paper is then the only RCT of the said topic in 25 years (see below). In the hierarchy of evidence based medicine, the Fares' paper has level 1 evidence (therapeutic) and a level A recommendation. Analysis of efficacy A MEDLINE search using the OVID interface, MESH headings "Orthopedic Manipulation" AND "Shoulder Dislocation" AND "Adult" and "limit to English language" yielded 75 papers. Most were expert opinions, observational studies, descriptive studies, retrospective studies, case series, and guidelines. If we limit our search result to RCT, only the Fares' paper is relevant. A search in the bestbets.org database using the keywords: "shoulder dislocation" yielded 10 results, three addressed the question of comparing the different methods of reduction. 4-6 And of the 3 best evidence topics, there were only 2 papers the Fares' and the Beattie's (Table 2). Cochrane's review included in the "Search Strategy" and "Search Outcome" did not yield any more paper other than these two. We employed techniques used in meta-analysis to combine the published data to re-examine the results. Both studies used "successful reduction" as the outcome and hence there is no heterogeneity in outcome measures. The Beattie's study had 111 patients (56 in the Milch's arm and 55 in the Kocher's arm), and the Fares' study had 154 subjects (53 in the Fares' arm, 51 in the Hippocratic arm and 50 in the Kocher's arm). After pooling the data, we have the results in Table 3 (Chi-square, 2-tailed significance test, significance level taken at 0.05). Although some previous studies suggested that Milch had 100% success rates, 7 those were case series and should be superseded by superior evidence. One merit of the FARES method is the speed of the reduction. Our experience concords with the Fares' groups in that the new technique can reduce the shoulder in a matter of 1 to 2 minutes (reduction time in the original paper was 2.36±1.24 minutes (mean±s.d.). In our limited experience, Spaso is also a quick method which is quite popular in Hong Kong. 8-11 However, the original paper on the FARES method did not compare Spaso. One of the criticisms that paper received was that the new method was used to compare an out-dated Hippocratic method instead of more modern techniques. But in Greece where this paper originated, the control arms were selected by a pre-trial survey which found that the Hippocratic and Kocher's methods were the most popular techniques in their locale. One of the merits which could not be reproduced in our case series is the reduction in pain. Despite the authors of the paper claimed that the procedure is relatively pain-free, some patients expressed pain in the procedure. For now, premedication is used in our setting at the doctor's discretion. Limitations The Accident and Emergency Department only managed 9 shoulder dislocations in the 3 monthperiod. The experience of our doctor is one limiting factor, and the case load is another. These may influence the choice of our reduction technique. An important issue on the efficacy of different reduction methods is the experience of the operator. One of the criticisms is that randomised controlled trial conducted in this clinical setting may not be possible and meaningful. In Fares' original paper, they tried to limit "1 of 3 first or second-year resident orthopaedic surgeons" to perform the reduction in order to minimise this effect. Nonetheless, RCT of this kind could not be conducted in an operator-blinded fashion and hence the studies easily carry a potential bias.

Tsoi et al./fares method for anterior shoulder dislocation 69 Table 2. A table showing the randomised controlled trials in the literature Date and Authors Reduction Number of Outcome Major study country method patients weakness 1986, Beattie Milch 111 Successful 1. No sample size estimation before the study, perhaps UK et al 2 vs. Kocher patients reduction leading to failure in reaching statistical significance; 2. No mentioning of premedication used; 3. Unclear whether baseline of the groups comparable; 4. Conclusion drawn not based on statistically significant results; 5. Study not blinded, but this seems unavoidable. 2009, Fares FARES 154 Successful 1. No sample size estimation before the study. Greece et al 3 vs. Hippocratic patients reduction 2. Use of old fashioned technique for comparison. vs. Kocher 3. Study not blinded, but this seems unavoidable. Table 3. Comparison of the efficacy of different methods of shoulder reduction FARES*(n=53) Hippocratic (n=51) Kocher (n=105) Milch (n=56) p-value Successful reduction 88.7% 72.5% 70.5% 69.6% 0.007 (CI 80.1%, 97.2%) (CI 60.3%, 84.8%) (CI 61.8%, 79.2%) (CI 57.6%, 81.7%) *The difference is significant as shown by the p value in favour of the FARES method. CI denotes 95% confidence interval Conclusion Anterior shoulder dislocation is a common large joint dislocation. There are no standard methods of reduction. A new technique called FARES was introduced by a Greek group recently with a higher success rate, speedy reduction and being almost painfree. We performed a survey to investigate the baseline pattern of our practice. In the 3-month period a total of 9 shoulder dislocations were collected and analysed. It was found that this new technique was popular amongst the staff, its success rate was high and the time required for reduction was short. References 1. Chung CH. Closed reduction techniques for acute anterior shoulder dislocation: from Egyptians to Australians. Hong Kong J Emerg Med 2004;11(3):178-88. 2. Beattie TF, Steedman DJ, McGowan A, Robertson CE. A comparison of the Milch and Kocher techniques for acute anterior dislocation of the shoulder. Injury 1986;17(5): 349-52. 3. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am 2009;91(12):2775-82. 4. Gendy M. Milch's technique versus Scapular Manipulation technique for reduction of anterior shoulder dislocation. [cited 2011 April 15]. Available from http://bestbets.org/bets/bet.php?id=277. 5. Ashton HR. Kocher's or Milch's technique for reduction of anterior shoulder dislocations. [cited 2011 April 15]. Available from http://bestbets.org/bets/bet.php?id=285. 6. Barton M. Kocher's or FARES method for reduction of anterior shoulder dislocations. [cited 2011 April 15]. Available from http://bestbets.org/bets/bet.php? id=2005. 7. Janecki CJ, Shahcheragh GH. The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res 1982;164:177-80. 8. Yuen MC, Yap PG, Chan YT, Tung WK. An easy method to reduce anterior shoulder dislocation: the Spaso technique. Emerg Med J 2001;18(5):370-2. 9. Yuen MC, Tung WK. The use of the Spaso technique in a patient with bilateral dislocations of shoulder. Am J Emerg Med 2001;19(1):64-6. 10. Yuen MC, Yap PG, Chan YT, Tung WK. The Spaso technique in reduction of anterior shoulder dislocation in the Accident and Emergency Department of Kwong Wah Hospital (Hong Kong) [Abstract]. Prehosp Disaster Med 1999;14(suppl 1):S78. 11. Yuen MC, Tung WK. Reducing anterior shoulder dislocation by the Spaso technique. Hong Kong J Emerg Med 2001;8(2):96-100.